Episode 1: Why TXA?

Any prehospital provider in Northeastern Indiana has heard extensively about tranexamic acid (TXA) lately. From what we are hearing, there is significant hesitation and reluctance using it. Personally, we believe that fear and trepidation are usually ground in misunderstanding, and truthfully ignorance. That being said, we are not claiming expertise or infallibility. Simply, we just believe that the way to combat ignorance is education and knowledge. Ignorance propagates poor clinical decision-making and, ultimately, jeopardizes our patient’s experience, whether or not that was our intent. As Charles Darwin so aptly put it, “[i]gnorance more frequently begets confidence than does knowledge…” So, let’s debunk the myths and unpack the information about tranexamic acid!

TXA has been used since the 1950s, primarily prophylactically in cardiovascular and orthopedic surgeries. Despite the drug being around for nearly seventy years, why is there so much misunderstanding about it? Only within the last five years has there been substantial research about TXA. Three studies were conducted fairly close together: CRASH-2, MATTERS, and WOMAN. In the CRASH-2 study, over 20k patients were tested with remarkable results. Despite significant mechanism of injury (MOI), there was a 1.5% improved mortality rate (150 lives saved!). The MATTERS trial was used in the military setting with horrendous injuries, i.e. IED blasts, multiple GSWs, etc. with similar results. The WOMAN trial is, perhaps, the least known study out of the three. The WOMAN trial identified that worldwide, there were approximately 100k deaths annually due to postpartum hemorrhage (PPH). The WOMAN trial had a very small sample size, about 500 women, but showed an overall improved mortality rate of 4.9%. PPH is a preventable cause of death, and something we should be considering TXA use in!

So now that we know a little about the history of TXA, what the hell does it do!? Let us start with the biggest misconception: TXA DOES NOT cause the body to form clots! TXA is an anti-fibrinolytic, or “anti-clot buster”, if you will. Following a gross traumatic injury, the body tears apart clots that it desperately needs to form because it is not used to the excessive fibrin production. TXA slows the process of fibrinolysis (clot destruction) down. TXA has a relatively short half-life of about two hours. Many have asked about the thrombogenetic effect (the body’s clot-producing predisposition). Bottom line, patients that were given TXA did infrequently develop pulmonary emboli and deep vein thrombosis; the authors of the MATTERS trial addressed this concern, though, and asked their audience to look at this incidence through the lens of trauma outcome. The likelihood of these patients developing these maladies was already exceedingly high to their MOI! TXA prevented these patients from going into hemorrhagic shock, thus, accomplishing the main objective.

What about fluid resuscitation? I’m glad you asked! The million-dollar question: what does crystalloid fluid do for patient perfusion and clotting capability? JACK CRAP!! There is no point filling an open container and diluting the body’s ability to properly perfuse and clot! The gold standard of EMS in mass trauma for decades was “two large bore IVs” and as many bags of saline/Ringers as you could fit before reaching the ED. Now…not so much. As Dr. Scott Weingart, ED Intensivist and author of the EmCrit Podcast, states so well, “Injection of a fluid that will increase BP has dangers in itself…If the pressure is raised before the surgeon is ready to check any bleeding that might take place, blood that is sorely needed may be lost”. For those that have it readily available, it is highly suggested to give a unit of packed RBCs alongside of the TXA for increased volume and perfusion.

The main purpose of this show was inform, enlighten, and to think outside of the box. The box is not bad, but if we stay there too long, it is damaging. Damaging to our growth as practitioners and to the overall outcome of our patient. We can no longer adopt the mentality that our care doesn’t affect over patient health.

DISCLAIMER

We by no means are encouraging the use of TXA outside of current protocols. We are just trying to provide a little bit of round table discussion stating that TXA might be able to be used in other situations beyond trauma. Other studies are being conducted about the use of TXA in dissecting AAA and Upper and Lower GI bleeding; as soon as we hear anything new or notable from those studies, we will update you all.

SOAPBOX MINUTE WITH MIKE

We encourage you all to read the studies for yourself, and to dig out as many nuggets of wisdom as you can! Good luck, be safe, and remain dedicated! We hold the trust of our families, friends, and communities in our hands. Trust must be earned. Earn it!

Anyone that tells that you that checklists are for rookies is an ass. Checklists are the anchor to an emergency. Checklists save lives and prevent mistakes. No one is too experienced to keep a checklist. If you’re administering TXA to a patient, chances are there are a lot of other things you have to worry about besides drug administration; i.e. airway control, pleural decompression, etc., so why not make things easier on yourself? Here’s our checklist for tranexamic acid (have I said checklist too many times?)

– TXA: 1000mg (1g)/10ml (other services may vary, but this is what I have seen carried locally.